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LABORATORY OF PATHOLOGY ONLINE POLICY MANUAL

GENERAL INFECTION CONTROL POLICIES

These procedures apply to all Laboratory of Pathology (LP) clinical staff who come in

contact with human tissues, blood, or potentially infectious materials: staff pathologists,residents and fellows in pathology, medical technologists, cytotechnologists, autopsy

assistants, photographers handling human tissues, histology technicians, and program support

staff.

I.   New employees receive training on Universal Precaution & Tuberculosis training in

collaboration with the Hospital Epidemiology Service. See the Universal Precautions

Overview for training information. In addition, all such employees receive instruction on the

 principles of infection control, with particular emphasis on mycobacterial diseases, and blood

and body fluid precautions. Principles of infection prevention and control are discussed in the

Residents' Manual that is given to each new resident upon the initiation of training. Universal

 precautions and biosafety are covered in the LP Safety Manual that is reviewed annually byall clinical employees of LP.

II. 

All employees who come in contact with blood, potentially infectious materials, or

human tissues are required to take annual Universal Precautions & Tuberculosis Training

sessions. The Safety Committee monitors compliance of technical personnel and will notify

supervisors of delinquencies or problems. The professional staff (MD’s) members are

monitored through the Clinical Center (CC) Credentials office.

III.  Employees receive basic instruction about tuberculosis exposure and use of barrier

 protection devices. All specimens with a potentially airborne route of transmission must be

manipulated in a biological safety hood. Departmental control measures are reviewed on an

annual basis and modifications made as necessary. Structural renovations that may assist in

infection prevention and control are instituted.

IV.  Compliance with Universal Precautions is monitored by individual supervisors. Non-

compliance with Universal Precautions is documented as part of annual performance

appraisals.

V.  Tuberculosis Surveillance Program. Healthcare workers who may be exposed to

unfixed human tissues (e.g. grossing surgical specimens, performing autopsies) or those who

see patients in the clinics (e.g. assist with FNA) must be enrolled in the OMS Tuberculosis

(TB) Surveillance Program. The LP Clinical Laboratory Manager, the OMS Nurse

overseeing the Tuberculosis Surveillance Program, and the Epidemiologist on the Hospital

Epidemiologist Service coordinate activities and data to ensure appropriate employees are

enrolled in the program on an ongoing basis, at least quarterly. New employees must report toOMS when they are hired for their initial physical and receive a PPD skin test if appropriate

and are recalled annually for repeat testing. It is the employees' responsibility to follow-up by

contacting OMS or by attending one of their walk-in clinics, after they receive their annual

notice. If the employee fails to follow-up, the employee is sent a second reminder notice.

Through a coordinated effort with OMS and HES, the employees who remain non-compliant

or not enrolled may receive an e- mail from the Clinical Laboratory Manager informing them

of the necessity to enroll and become compliant. Any healthcare worker who tests positive

for a PPD will receive appropriate counseling and follow-up by OMS, including education on

TB symptoms.

VI.  Employees are similarly counseled by OMS regarding OSHA requirements for

hepatitis B vaccination, and are required to comply with OSHA regulations.VII.  A retroviral surveillance program is available for personnel but is not mandatory.

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VIII.  All specimens are treated as potentially infectious by using Universal Precautions.

IX. 

Supervisors must provide specific safety training related to the work that students or

visitors would do.

X. 

Suspected cases of CJD should be communicated to LP by the healthcare provider via

the order placed in the CRIS; however, a CJD or prion disease patient does not always

 present with symptoms of CJD. These cases are usually diagnosed at the time of autopsy,however, precautions for containment are carried out on surgical specimens from the

following patients:

A.  Patients with neurodegenerative disease if CJD has entered the differential diagnosis

B.  Patients with a familial prion disease

C.  Recipients of tissues from human cadavers (pituitary derived hormones or dura mater)

XI.  Suspected cases of CJD should be communicated to LP by the healthcare provider via

the order placed in the CRIS; however, a CJD or prion disease patient does not always

 present with symptoms of CJD. These cases are usually diagnosed at the time of autopsy,

however, precautions for containment are carried out on surgical specimens from the

following patients:

. 

Pathologists will notify technical staff of precautions that need to be taken on a case- by-case basis. Departmental Procedures for the Autopsy Service (see below) can be adapted

for other service areas as needed.

A. 

Unusual or unexpected preliminary results are called to both the surgeon and the

clinical care team within 24 to 48 hours of collection. A note should be placed in the report

stating when and who was notified.

B.  All cases suspected of CJD or prion disease are sent to a reference laboratory for

confirmation.

C.  Suspected and confirmed cases are reported to the Hospital Epidemiology Service

(HES, 496-2209) with a note in the report stating when and who was notified.

D. 

The turn around time interval between specimen receipt and final report is monitored

and reviewed on a periodic basis to assure shortest result reporting time.

XII. 

All healthcare workers shall practice good hand hygiene to reduce the risk of

transmission of organisms to patients, themselves, and coworkers. Careful attention should be

given to hand hygiene after removal of gloves and especially before touching the eyes or

mucosal surfaces. General hand hygiene practices are:

.  Indications for hand washing include:

i.  Before and after patient contact

ii.  Contact with environmental surfaces in the immediate vicinity of

 patients.

iii.  After glove removal.

iv. 

Before eating and after using the restroom.A.  Techniques for hand hygiene (See Special Respiratory Isolation

Procedure)

.  Select the proper amount of hand hygiene solution or agent and wash hands

thoroughly.

i. 

When decontaminating hands with alcohol-based hand rub, apply one

full pump depression of the product to palm of hand and rub hands

together, covering all surfaces of wrists, hands, fingers, and nails, until

hands are dry. This should take 15 to 25 seconds. Follow

manufacturer’s recommendations regarding product use.

ii.  Soap and water are recommended for visibly soiled hands. Wet hands

first with warm water, apply product and rub hands vigorously for atleast 15 seconds, covering all surfaces of wrists, hands, fingers, and

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nails. Rinse with water and dry with disposable towel. Use towel to

turn off faucet. The use of compatible lotions and creams are

recommended to prevent or minimize dryness and irritation. Central

Hospital Supply can provide guidance on product selection, if needed.

iii.  Avoid the use of bar soaps and multiple-use towels.

B. 

Indications for, and limitations of, glove use:.  Gloves are worn for all contact with blood, body fluids and other potentially

infectious materials, and non-intact skin.

i.  Hand contamination may occur as a result of small, undetected holes in

gloves.

ii.  Contamination may occur during glove removal.

iii.  Wearing gloves does not replace the need for hand hygiene.

iv.  Failure to remove gloves after caring for a patient may lead to

transmission of microorganisms from one patient to the other.

v.  Supervisors and safety officers of each area should monitor hand

hygiene technique and provide feedback to employees as needed.

XIII. 

Lab coats are cleaned using the NIH Laundry Service:. 

Using indelible ink, write your name and room number on the tag of your lab coat.

i.  Complete a laundry slip. 

ii. 

Place lab coats in a laundry bag or plastic bag.

iii.  Deliver bag to lab coat bin outside of room B1N-35A.

iv. 

Clean lab coats will be delivered back to the room number on the lab coat.

Last Updated 12/28/2009 10:55:44 AM

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